In the recent election, jobs and the economy weighed most heavily on the minds of voters. Although the two presidential candidates espoused a different approach to health care reform, Academy CEO David W. Parke II, MD and other leaders believe that substantial system change would have proceeded regardless of the election outcome. “The reform drivers, particularly the cost driver, made the status quo an unsustainable option for either party,” said Dr. Parke, “and the amount of money invested in system change means that the train has long ago left the station.”

In particular, there are three important items that will have a greater and more immediate impact on ophthalmology than either election outcome, according to Michael X. Repka, MD, the Academy’s medical director for governmental affairs. These include the roughly 13 percent cut in cataract surgery payments imposed by the Centers for Medicare and Medicaid Services in the 2013 Medicare fee schedule; the looming nearly 27 percent cut in Medicare reimbursement triggered by the sustainable growth rate (SGR); and the possible 2 percent cut due to the sequestration process (triggered when a bipartisan joint congressional committee failed to agree on $1.2 billion in cuts last year).

SGR and sequestration. Congress could avert both the SGR cuts and sequestration before they take effect Jan. 1, Dr. Repka said, but they will have to address these issues at the same time they are dealing with expiring tax cuts, known as the fiscal cliff. “Will they let any cut take place? We don’t know,” he said during a press conference at the Academy’s Joint Meeting in November in Chicago.

Averting the cuts requires taking the money out of other parts of the budget. Under some proposals, that could mean robbing Dr. Peter to pay Dr. Paul. Dr. Repka said one idea for averting the SGR cut would reduce funding for graduate medical education. But according to Robert Copeland, MD, a 2008 study found that funding for graduate medical education needs to be increased by 30 percent to help address a looming shortage in physicians, particularly specialists. (For more on graduate medical education, watch Dr. Parke’s short video at http://youtu.be/dlx-KxyqU8Q.)

Cataract surgery cuts. While both SGR and sequestration cuts are essentially triggered by a shortage in funds, the cataract surgery cut was based on a recent survey commissioned by CMS. The Academy and the American Society of Cataract and Refractive Surgery participated in the survey. Among its findings was that cataract surgery times have decreased to an average of 21 minutes, from 35 minutes. The AMA/Specialty Society Relative Value-Scale Update Committee, known as the RUC, negotiates the relative work values of procedures and advises CMS accordingly.

Because CMS bases reimbursement to physicians on the relative work values, cataract surgery payment was reduced to reflect the advances that have sped up the procedure. Dr. Repka said this specific reimbursement “won’t be revalued probably for a minimum of five years unless there is a substantial change in how the service is delivered.” The good news is that strong ophthalmology participation in several CMS incentive programs, such as e-prescribing and the Physician Quality Reporting System, could potentially offset some of these cuts for participating ophthalmologists, Dr. Repka noted.

Even if Congress agrees on a plan to avert the SGR and sequestration cuts, however, Dr. Parke reports that medicine faces significant change, the nature of which “isn’t completely understood, and for good reason.” He was speaking of the yet unwritten regulations that will implement the 2010 health care reform law, as well as the larger economic factors that would have forced changes even under a Romney presidency.

“The drivers of change are there. They’ve been there since the beginning,” Dr. Parke said. “The biggest driver is cost.” While the average American 65 years or older has $61,000 saved in retirement, Dr. Parke noted, the typical cost of health care for that individual’s remaining years of life is $300,000.

Such a difference between the cost and the actual funds for health care makes change unavoidable. Dr. Parke said that although physicians will still be able to achieve their underlying goal of treating patients, employment models are likely to change. “More of us will be employed by hospitals … by big groups,” he suggested.

But at the same time, Dr. Parke noted, ophthalmologists could expect to have more control over their practices than peers in other specialties. “Ophthalmology isn’t cardiology,” he said, referring to that specialty’s skyrocketing employment by hospitals. “Ophthalmologists aren’t on the shopping list for most hospital CEOs.” And though solo practice options may become most feasible in more rural areas, Dr. Parke noted that residents “will have the whole spectrum of options” when they complete training.

However the practice of medicine changes in the upcoming decades, Dr. Parke said the best thing for young ophthalmologists to do is “become the best doctors they can be.”